Intervertebral disc excision in community health centers 

Orthopedic paper VII

Intervertebral disc excision in community health centers   

OPERATIVE TREATMENT OF PROTRUSION OF THE LUMBAR INTERVERTEBRAL DISC IN A COMMUNE’S HEALTH CENTER

ABSTRACT

Objective: To assess the long-term efficacy of surgical treatments for lumbar disc herniation (LDH) in a communal healthcare setting.

Methods: This retrospective clinical review analyzes 104 cases of protrusion of the lumbar intervertebral disc that underwent surgical intervention between 1974 and 1980 in a health center within a people’s commune. A comprehensive postoperative follow-up was conducted for periods ranging from 2 to 8 years, with an average follow-up duration of 5 years. The study elaborates on surgical methods employed and presents detailed observations and experiences gathered over the years.

Results: The outcomes of the 104 operated cases were classified as follows: excellent in 68 cases (65.4%), good in 22 cases (21.2%), fair in 10 cases (9.6%), and failure in 4 cases (3.8%). Various exposure techniques such as fenestration and hemilaminectomy were compared, highlighting the importance of complete nerve root decompression. Furthermore, infection control measures and strategies to mitigate postoperative intraspinal hematoma were discussed.

Conclusion: Surgical treatment of LDH in a communal healthcare setting has demonstrated significant efficacy, with a vast majority of patients (86.6%) experiencing good to excellent outcomes. Key insights include the comparable efficacy of fenestration over hemilaminectomy in most cases and the critical role of meticulous decompression and infection control in postoperative success.

Intervertebral disc removal surgery for treating pain in the lumbar and leg regions caused by lumbar disc herniation is a widely accepted etiological treatment. While this procedure has become quite common in hospitals above the county level, it is still less frequently performed in community health centers. Between 1974 and 1980, under the direct guidance of Professor Xu Jingbin, we performed 104 lumbar intervertebral disc removal surgeries at community health centers. A follow-up over a period of 2 to 8 years post-surgery indicated that the vast majority of cases had satisfactory outcomes. Below are some insights on how to improve surgical outcomes in under-resourced community health centers:

General Information

Out of the 104 cases, 85 were male and 19 were female. The oldest patient was 56, and the youngest was 23. There were 49 cases of disc herniation between the 4th and 5th lumbar vertebrae, 31 cases between the 5th lumbar and 1st sacral vertebrae, 22 cases of dual herniations, and 2 cases between the 3rd and 4th lumbar vertebrae. In two cases, the herniated disc nucleus had penetrated into the spinal canal, and 12 cases were accompanied by the formation of bone spurs.

Based on the efficacy assessment standards by Ma Zhiyao et al.[2], the statistical results of surgical outcomes are as follows:

Clinical Insights and Observations

1. Exposure Techniques: Out of 104 cases, eight utilized hemilaminectomy while the remaining employed the "fenestration" technique, including the 12 cases that necessitated bone spur removal. Through direct surgical practice and observation, we found no appreciable difference in exposure between the fenestration and hemilaminectomy methods. Hence, fenestration is generally recommended unless specific conditions, such as disc nucleus intrusion into the spinal canal, dictate otherwise. Utilizing fenestration tends to preserve facet joints and minimize tissue damage, facilitating early postoperative mobility and reducing the risk of nerve root adhesion. In our fenestration group, all patients began ambulatory activities between 3-5 days postoperatively with no observed complications.

2. Decompression Considerations: Armstrong pointed out in 1951 that dissatisfaction with surgical treatment of lumbar disc herniation was either due to diagnostic errors or failure to entirely eliminate the causative pathology. With advancements in medical technology, the likelihood of misdiagnosis or surgical omission has been minimized. Achieving "complete decompression" has thus gained prominence. After exposing the herniated disc and safeguarding the nerve root, a small scalpel is used to incise around the periphery of the protruding disc. Subsequently, pituitary forceps are used to remove the protruding disc and degenerative tissue from the disc space. This approach aims to achieve "complete clearance," not just removal of the nucleus pulposus, and has been found effective for comprehensive nerve root decompression and recurrence prevention.

3. Infection Control Measures: Postoperative infection, particularly within the intervertebral space, is a severe complication causing substantial patient distress and elongated recovery timeframes. This is especially significant in less well-equipped grassroots healthcare facilities. To mitigate infection risks, strict aseptic techniques are adhered to. Additionally, the cleared disc space is routinely irrigated under pressure with a 1:1000 Betadine solution. Following irrigation, the surgical site is occluded with Betadine-soaked gauze for approximately three minutes, capitalizing on Betadine's broad-spectrum, high-efficacy, and non-resistance features, which show no adverse effects on neural tissues.

4. Mitigation of Postoperative Intraspinal Hematoma: Given that the spinal canal should remain free from foreign material, traditional methods involving sutures or muscle tissue for hemostasis are avoided. Pressure-based methods are thus the primary approach for controlling bleeding. Even though minor postoperative intraspinal bleeding is somewhat inevitable, we employ appropriate drainage techniques. Specifically, a small amount of Betadine is intentionally left in the surgical site to dilute any residual bleeding, making it easier to drain. Rubber drainage strips are conventionally placed and removed after 48 hours, with observed drainage volumes ranging from 40 to 250 microliters, demonstrating the efficacy of this approach.

References

[1] Xu Jingbin. "Analysis of the efficacy of LDH," Chinese Journal of Surgery 4421, 1956 

[2] Ma Zhiyao et al. "Effects of surgical treatment of LDH," Chinese Medical Journal 5:51, 1965 

[3] Lu Yupu et al. "Surgical treatment of LDH," Chinese Journal of Orthopedics 2:77, 1981 

[4] OPERATIVE TREATMENT OF PROTRUSION OF THE LUMBAR INTERVERTEBRAL DISC IN A COMMUNE’S HEALTH CENTER, Ding Ming-xiu, Nanling Health School, Anhui 

This article was originally published in Proceedings of the Third Orthopedic Academic Conference in Anhui Province"
Ding Mingxiu, Nanling County Health Continuing Education School;
Instructors: Xu Jingbin, Li Mingjie
09/01/1983

from 在基层公社卫生院开展椎间盘摘除手术的体会 

【李名杰从医67年论文专辑】（电子版）

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